Linda is 34 years old. She is the mother of two busy boys, a dynamic organiser, and a real go-getter with a high-powered job. She, like her husband, smokes about 25 cigarettes per day. But, unlike her husband, she has elevated cholesterol levels. And, unlike her husband, she’s on the Pill.

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Her risk of a heart attack is 13 times higher than her non-existing, non-smoking Pill-popping twin. And that exactly is the clue: the Pill plus smoking is a deadly combination for heart attack risk, with smoking responsible for the bulk of the increased risk.

If you’re on the Pill and you smoke, abandon your cigarettes immediately, say the experts of the American Heart Association. And if you have high blood pressure, and you are on the Pill, do not smoke. This is the view of researchers around the globe.

Linda is one of about 100 million women in the world of childbearing age using oral contraceptives. Some are using the new versions, known as third generation Pills, and some are using the older ones, the second generation Pills.

Doctors have known since the 1960s that first and second generation oral contraceptives can increase the risk of heart disease. Birth control pills increase the chance of blood clots and thus of stroke and heart attack.

In an effort to improve safety, drug companies have lowered the oestrogen levels and varied the types of progesterones.

How safe are the new oral contraceptives really?
In a new and comprehensive Dutch study on more that 1000 women, doctors have found the risk for a heart attack or stroke about three times greater for women using first-generation birth control pills compared to women who had not been on the Pill.

The risk for a heart attack or stroke was 2,4 times greater with second-generation pills, with third- generation pills carrying about the same risk as the second-generation pill.

Other studies have also shown a greater risk of lung-threatening blood clots or heart attacks and stroke with third generation pills, especially in young women.

Against this background three leading drug companies are preparing to defend a group action suit in Britain's High Court over alleged side effects of the pill. More than 100 women are suing the companies claiming the firms failed to protect them from harmful side effects of the pill. The case focuses on four third-generation contraceptive pills introduced in the 1980s.

The women, who range in age from the teens to the 30s, claim they have suffered health problems such as stroke and paralysis. Seven women involved in the claim have died.

Even the drug companies involved say that third-generation pills top the risk list: About five women in every 100 000 not taking the Pill will develop blood clots. With the second-generation pill that goes up to 15 women in every 100 000, and with third-generation pills the risk is thought to be 25 in every 100 000 women, the pharmaceutical spokesperson explained.

The jury is still out on the matter which is safest: second- or first-generation birth control pills. However, even the greatest risk of a heart attack from oral contraceptives now in use can still be regarded as very slight: it is adding 25 more heart attacks in 100 000 women in the course of a year – that is two to three added for every 10 000 heart attacks.

Doctors agree that the risk of developing blood clots may be higher for older women and those with an already increased risk due to obesity, high blood pressure and smoking.

According to a South African cardiologist: “Today’s low-dose birth control pills carry a much lower risk of heart attack and stroke than the early Pill did. The exception is in women who smoke or have high blood pressure.“

The real danger is smoking
No matter which Pill, if you smoke about 25 cigarettes per day, you increase your risk at least fourfold but maybe even up to 30-fold, according to several studies. The Pill’s singular effect compared to that of the cumulative effect of smoking plus the Pill is like a hick-up to a thunderstorm.

The huge effect of smoking is a troubling finding because the number of smokers amongst South African women has increased in the last decade, especially amongst younger women.

The American Heart Association's recommendations regarding oral contraceptives are loud and clear:

• If you don’t smoke and don’t have high blood pressure or other risk factors for heart disease, a low-dose oral contraceptive can be used
• If you want to use the Pill, or if you are already using it, don’t smoke, whatever your age.

Danger signs
Most side effects of the Pill do not require medical attention. However, consult your doctor if you experience any of the following:

• Severe abdominal pain
• Severe chest pain or shortness of breath
• Severe throbbing headache/weakness on one side of the body
• Eye problems like flashing lights or vision disturbances
• Severe leg pains
• Weakness on one side of the body

You can take charge of your own health
Women on the Pill can take five steps to lower their risk for heart disease:

• Stop smoking
• Exercise at least three times per week
• Make sure your hypertension and diabetes (if applicable) are treated effectively
• Lower your fat intake
• Lose weight if you are overweight

And what about oestrogen?
Britain's Medicines Control Agency (MCA) recently advised that combined hormone replacement therapy (HRT) may increase the risk for heart disease in women. Proponents of HRT have previously argued that while the treatment may slightly increase the risk for breast cancer, it may act as a protector against heart disease and osteoporosis.

But now the MCA recommends that the text of the inserts of oestrogen and HRT must be changed to indicate that claims to this extent cannot be justified.

The American Heart Association also advised that HRT should not be initiated solely for its potential protective effects against heart disease in the light of the conflicting scientific studies. HRT should be terminated if a woman suffers a heart attack or stroke.

The most important message for women on the Pill: take the Pill but kick the smoking habit.

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